HospitalInspections.org

Based on record review and interview, the hospital failed to perform obstetric (pregnant patient) medical screening exams, observation of pregnant patients (including fetal monitoring) sufficient to meet acceptable standards of practice, record complete vital signs, and repeat clean catch urinalysis (test of urine) for 4 (P#s 47, 48, 50, and 55) of 10 obstetric (pregnant) patient records reviewed. This failed practice has the potential to result in fetal (baby) complications and possibly death of the mother or baby. The findings are:


P#50

A. Review of journal article "Expert review of Obstetrics and Gynecology" dated January 2011 revealed, "Trauma is the leading nonobstetric cause of morbidity and mortality (sickness, disease, and death) in pregnancy; approximately one out of every 15 pregnancies is complicated by trauma. Motor vehicle accidents are a major cause of trauma during pregnancy. Severe injury occurs in approximately 10% of cases, a situation associated with high likelihood of preterm delivery, placental abruption, cesarean delivery, and increased maternal and fetal mortality. Nevertheless, obstetric complications may also occur with less severe injuries. All pregnant trauma patients should be managed according to Advanced Trauma Life Support guidelines. In total, 2-6 hours of observation with fetal monitoring are recommended for pregnant trauma patients who are not admitted."


B. Record review of P#50's Admission consent revealed patient was admitted to the emergency department on 06/14/19 at 1:54 pm.


C. Record review of P#50's Chief Complaint dated 06/14/19 electronically signed at 3:52 pm revealed, patient was "a 37 year old who was involved in a motor vehicle accident and she has no major acute injury no loss of consciousness no contusions she is a 37 with a pregnant patient report (sic) having a increased frequency of contractions since the accident but no vaginal bleeding patient is here for further evaluation and care."


D. On 12/12/19 at 3:00 pm during interview, S#4 MD (Medical Doctor) confirmed the rate of speed of the vehicle P#50 was operating when the accident occurred, whether P#50 was wearing a seatbelt, and whether the airbag was functional should have been documented in the assessment and may have determined the length of observation required for P#50 after a motor vehicle accident.


E. Record review of P#50's ED Course (Emergency Department course) dated 06/14/19 revealed patient was transferred to Labor and Delivery (from the Emergency Department) at 2:56 pm.


F. Record review of P#50's Clinical Notes dated 06/14/19 at 3:47 pm revealed, "34 YO (year old) with iup (intrauterine pregnancy at 37.6 weeks complaining of a MVA (motor vehicle accident) this afternoon, was a driver, and hit on drivers front, airbags were not deployed, patient was medically cleared in ED, here with history of irregular uterine contractions, but feels they have worsened soince (sic) accident, denies SROM (spontaneous rupture of membranes), vaginal bleeding, baby active."


G. Record review of P#50's Stored Fetal Strip dated 06/14/19 revealed fetal monitoring was initiated at 3:06 pm.


H. Record review of Discharge documentation dated 06/14/19 revealed P#50 was discharged from Labor and Delivery at 3:55 pm.


I. On 12/12/19 at 3:10 pm during interview, S#74 RN (Registered Nurse) confirmed an obstetric physician (doctor dealing with pregnancy related issues) did not physically evaluate P#50 prior to discharge from L&D (Labor and Delivery) and patient was not monitored in the Labor and Delivery area for a full hour (based on documentation).


P# 47

A. Record review of P#47 Admission (Discharged) record revealed patient was admitted 05/29/19 at 4:49 pm, discharged from L&D at 6:55 pm with complaints of abdominal cramping/abdominal discomfort and was 33 week pregnant.


B. Record review of Vital signs revealed P#47 complained of a pain score of "7" at 5:20 pm. No repeat of pain score prior to discharge was documented.


C. Record review revealed no blood pressure (BP) was recorded during the approximately 2 hours the patient was observed and during a scan of the bladder performed in L&D.


D. On 12/12/19 at 2:40 pm during interview, S#74 RN confirmed an obstetric physician did not physically evaluate P#47 prior to discharge from L&D (Labor and Delivery), BP was not recorded (based on documentation) and a repeat pain assessment was not conducted. S#74 also confirmed the expectation is to take a full set of vital signs upon admission to L&D.


E. Review of "Summary of ACOG (American College of Obstetrics and Gynecology) for Perinatal Care" dated 2007 revealed, vital signs should be monitored "Every visit."


P#55

A. Record review of P# 55's Medical History dated 07/05/19 revealed patient had a history of "Seizure, Anxiety, Depression, and PTSD (post-traumatic stress disorder)."


B. Record review of P#55's Admission Information dated 07/12/19 revealed, patient arrived at 1113 (no am or pm) in Labor and Delivery.


C. Record review of P#55's Nurse Triage Note dated 07/12/19 at 11:47 pm (sic) revealed patient was 36 weeks pregnant, admitted to L&D with a chief complaint of "Headache."


D. Record review of P#55's All Results - Labs dated 07/12/19 revealed labs were collected at 1152 (no am or pm).


E. Record review of P#55's Admission (Discharged) record dated 07/12/19 at 1132 pm revealed, "Voices she was sitting on the floor when she felt the seizure coming. Pt voices she has court scheduled for Monday and that's what induced the seizures. My neurologist diagnosed me with pseudo seizure (Nonepileptic seizures are caused by something other than epilepsy - typically by psychological conditions) and anxiety induced seizures and no medications were prescribed. States she had another seizure today at 0930 (9:30 am). Husband found her on the floor 'vomit on the floor'."


F. Record review of P#55's Discharge Instructions revealed P#55 was discharged on 7/12/19 at 12:52 pm.


G. Review of "Neurovascular disorders in pregnancy: A review" published in Obstet Med dated Dec 2019 revealed, "While rare, neurovascular disorders that occur in pregnant or postpartum women are associated with high morbidity and mortality, thus necessitating prompt identification and treatment. The most common symptoms include headache, focal neurological features, and seizures. Factors such as pregnancy-related hypercoagulability (increased blood clotting) and hemodynamic changes put women at risk for neurovascular disorders in the third trimester and early postpartum period."


H. On 12/12/19 at 2:55 pm during interview, S#79 RN confirmed an obstetric physician did not physically evaluate P#55 prior to discharge from L&D (Labor and Delivery) and patient and baby were monitored (fetal monitoring) for approximately 2 hr. and 30 minutes. S#79 also confirmed that P#55 was taking Keppra (medication used to control seizures) at some point, but it was unknown when the patient stopped taking the medication or if the seizures were a chronic medical problem. S#79 also confirmed documentation revealed no temperature was taken during the visit to L&D 07/12/19 for P#55.


I. On 12/12/19 at 3:00 pm during interview, S#4 MD confirmed RNs could use additional parameter guidelines when conveying information to physicians and determining discharge criteria.


P#48

A. Record review of P#48's Admission (Discharged) dated 07/02/19 revealed P#48 was admitted to L&D at 0102 (1:02 am) with a chief complaint of "abdominal pain, shooting into the vagina". P#48 was 32 weeks pregnant. P# 48 was discharged at 03:14 am.


B. Record review of all results - Lab dated 07/02/19 revealed urine drug screen was positive for opiates (patient previously prescribed Norco 5-325 mg per tablet) and cannabinoids (marijuana). In addition, the clean catch urine (method of collecting urine to make sure bacteria from the vagina does not get into the urine specimen) results revealed, "Multiple organisms present, each less than 10,000 CFU (colony forming units). These organisms commonly found on external and internal genital are considered to be colonizers (normally occurring on the genitalia). No further testing performed."


C. Record review of facility Stored Fetal Strip for P#48 revealed fetal monitoring began at 0117 (1:17 am) on 07/02/19.


D. On 12/12/19 at 3:00 pm, during interview, S#77 confirmed record review revealed P#48 did not have a repeat clean catch urine collected, despite the previous urine collection having contaminants in the specimen and the presentation of abdominal pain. S#77 also confirmed documentation revealed OB MD (physician dealing with pregnancy related issues) did not physically see the patient during the L&D visit on 07/12/19. Furthermore, no documentation in the records indicated P#48 was provided education or counseling related to the drug use.


E. Review of HHS Public Access article dated 2012 "Lasting impacts of prenatal cannabis exposure and the role of endogenous cannabinoids in the developing brain" revealed, Marijuana abuse during pregnancy represents a major health problem owing to its potential consequences on neural development. Prenatally (period of pregnancy prior to delivery) cannabis-exposed children display cognitive deficits suggesting that maternal consumption has interfered with the proper maturation of the brain (developmental delays)."


Other

A. Record review of Governing Body Minutes dated June 2019 revealed, no evidence of OB nurses receiving credentialing for assessments of OB patients.


B. On 12/12/19 at 10:30 am during interview, S#5 Risk Manager confirmed that no OB nurses were credentialed to assess and discharge patients by the Board of Trustees. S#5 further confirmed the facility policy was not being followed.


C. Record review of facility policy "Emergency Department Screening of Obstetric Patients" dated 04/26/19 revealed, The labor and delivery registered nurse is a Qualified Medical Person who may perform the Medical Screening Evaluation for a pregnant woman in labor or other labor related complaints."


D. Record review of facility EMTALA policy dated 08/11/17 revealed, "Qualified Medical Person or Personnel" means a category of professionals other than licensed physicians who have been approved by the hospital's Board of Trustees as qualified to administer one or more types of medical screening examinations and complete/sign a certification for transfer in consultation with a physician."







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